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SAN �OAQUIN =�� _I-�'r-�;. `� COUNTY �y�. `� �"� .,�r Greoi•ness grows here. Environmental Health Department SITE MITIGATION WELL &BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 1301 E Lockeford Street City/state/zip Lodi, CA 95240 Phone 559.647.7766 Cross Street E Lockeford Street/N Cluff Avenue APN 049-34-026 Property Owner* Ken Sommers Phone Address Not Provided City/State/Zip NA c-s� contractorEnvironmental Control Associates, Inc. (ECA) License# 695970 .� Q �Q�ZZPhone Address 3011 Twin Palms Drive City/State/ Consultant/sub-Contractor Partner Engineering and Science, Inc. License# N,q Address 1544 Eureka Road, Suite 180 city/state/zip Roseville, CA 95661 559.647-7766 916.417.6858 Phone 559.907.7502 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA �[ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER SOIL BORING ❑ PUSH POINT (GP/CPT) CONDUCTOR CASING ❑Yes j�No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (AirsparQe, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH U N K TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE JAI PIPE ❑ OTHER � OTHER: Direct Push GROUT SEAL PUMPED? Yes ❑ No (Note• Maximum Freefall Depth is 30 Ft) WELLISOILBORINGIDs B1 through B4 GROUT SPECIFICATIONS�rOUt via bounty requirements. Nea�,Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION ME -i #WELLS TO BE DESTROYED ❑OVER -BORE WELL IDs ❑PRESSURE GROUT GROUT SPECIFICATIONS ❑EXPLOSIVES +rr�. IOD: (CHECK ALLTHA� PPLY) ��y��M+o��b-- DIAMETER of inches to depth of feet „�� To depth of feet below surface 41�� From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: NO roundwater to be collected Soil and soil as Soil as robe constructed at 5 feet b s 9 � g� 9 p g within soil boring. 11herre.�y (certify that I am authorized to complete this application and that the work will be done in accordance with II �� 1�an Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed Print Na e Lauren Hinck Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information Title/Company Project Geologist -Partner Engineering and Science Inc. Date 4/20/2022 DEPARTMENT USE ONLY Date Issued: FA Name � '� �.�� �rf �( nC FA Address � 3 (� � ` �� FA# ©d �2� PR# �J.'3� (Q FA PE � WP Reviewed By � Work Plan Date �� ❑ C-57 �I�C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval MFR COMMENTS/ ND IONS: GtN�,� � � ��1�� O r �� � � I �� ��[ �� r�� % ? l WP TYPE PE SC FEE INFO $152 x � AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit Zl�� 3 �3 6 � � � � �V ✓� 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � vvww.sjcehd.com EHD 29-01 OS -01-17 �� /� `��1� � I e L�� I '� O� � /1 ite itigati�W�'e i it Application